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  7. NPI Record 1275691339

MED-1 MEDICAL CENTER PROFESSIONAL CORPORATION
Complete NPI Record 1275691339
Clinic/Center - Corporate Health in Modesto, CA

NPI Status: Active since December 04, 2006

Contact Information

3508 DALE RD
MODESTO, CA
ZIP 95356
Phone: (209) 574-1355
Fax: (209) 571-8204

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Business Mailing Address City Name
  7. Provider Business Mailing Address State Name
  8. Provider Business Mailing Address Postal Code
  9. Provider Business Mailing Address Country Code If outside U S
  10. Provider Business Mailing Address Telephone Number
  11. Provider Business Mailing Address Fax Number
  12. Provider First Line Business Practice Location Address
  13. Provider Business Practice Location Address City Name
  14. Provider Business Practice Location Address State Name
  15. Provider Business Practice Location Address Postal Code
  16. Provider Business Practice Location Address Country Code If outside U S
  17. Provider Business Practice Location Address Telephone Number
  18. Provider Business Practice Location Address Fax Number
  19. Provider Enumeration Date
  20. Last Update Date
  21. Authorized Official Last Name
  22. Authorized Official First Name
  23. Authorized Official Title or Position
  24. Authorized Official Telephone Number
  25. Healthcare Provider Taxonomy Code 1
  26. Provider License Number 1
  27. Provider License Number State Code 1
  28. Healthcare Provider Primary Taxonomy Switch 1
  29. Other Provider Identifier 1
  30. Other Provider Identifier Type Code 1
  31. Other Provider Identifier State 1
  32. Other Provider Identifier Issuer 1
  33. Other Provider Identifier 2
  34. Other Provider Identifier Type Code 2
  35. Other Provider Identifier State 2
  36. Other Provider Identifier Issuer 2
  37. Other Provider Identifier 3
  38. Other Provider Identifier Type Code 3
  39. Other Provider Identifier State 3
  40. Other Provider Identifier Issuer 3
  41. Other Provider Identifier 4
  42. Other Provider Identifier Type Code 4
  43. Other Provider Identifier State 4
  44. Other Provider Identifier Issuer 4
  45. Other Provider Identifier 5
  46. Other Provider Identifier Type Code 5
  47. Other Provider Identifier State 5
  48. Other Provider Identifier Issuer 5
  49. Other Provider Identifier 6
  50. Other Provider Identifier Type Code 6
  51. Other Provider Identifier State 6
  52. Other Provider Identifier Issuer 6
  53. Other Provider Identifier 7
  54. Other Provider Identifier Type Code 7
  55. Other Provider Identifier State 7
  56. Other Provider Identifier Issuer 7
  57. Other Provider Identifier 8
  58. Other Provider Identifier Type Code 8
  59. Other Provider Identifier State 8
  60. Other Provider Identifier Issuer 8
  61. Other Provider Identifier 9
  62. Other Provider Identifier Type Code 9
  63. Other Provider Identifier State 9
  64. Other Provider Identifier Issuer 9
  65. Other Provider Identifier 10
  66. Other Provider Identifier Type Code 10
  67. Other Provider Identifier State 10
  68. Other Provider Identifier Issuer 10
  69. Other Provider Identifier 11
  70. Other Provider Identifier Type Code 11
  71. Other Provider Identifier State 11
  72. Other Provider Identifier Issuer 11
  73. Other Provider Identifier 12
  74. Other Provider Identifier Type Code 12
  75. Other Provider Identifier State 12
  76. Other Provider Identifier Issuer 12
  77. Other Provider Identifier 13
  78. Other Provider Identifier Type Code 13
  79. Other Provider Identifier State 13
  80. Other Provider Identifier Issuer 13
  81. Other Provider Identifier 14
  82. Other Provider Identifier Type Code 14
  83. Other Provider Identifier State 14
  84. Other Provider Identifier Issuer 14
  85. Other Provider Identifier 15
  86. Other Provider Identifier Type Code 15
  87. Other Provider Identifier State 15
  88. Other Provider Identifier Issuer 15
  89. Other Provider Identifier 16
  90. Other Provider Identifier Type Code 16
  91. Other Provider Identifier State 16
  92. Other Provider Identifier Issuer 16
  93. Other Provider Identifier 17
  94. Other Provider Identifier Type Code 17
  95. Other Provider Identifier State 17
  96. Other Provider Identifier Issuer 17
  97. Other Provider Identifier 18
  98. Other Provider Identifier Type Code 18
  99. Other Provider Identifier State 18
  100. Other Provider Identifier Issuer 18
  101. Other Provider Identifier 19
  102. Other Provider Identifier Type Code 19
  103. Other Provider Identifier State 19
  104. Other Provider Identifier Issuer 19
  105. Other Provider Identifier 20
  106. Other Provider Identifier Type Code 20
  107. Other Provider Identifier State 20
  108. Other Provider Identifier Issuer 20
  109. Is Organization Subpart
  110. Authorized Official Name Prefix Text
  111. Authorized Official Credential Text

Complete NPI Dataset

This page represents the complete record for NPI 1275691339. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1275691339
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address: 3508 DALE RD
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City Name: MODESTO
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: CA
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 953560552
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number: 2095741355
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Fax Number: 2095718204
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address fax number’’.
Provider First Line Business Practice Location Address: 3508 DALE RD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: MODESTO
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: CA
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 953560552
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 2095741355
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 2095718204
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 12/4/2006
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 8/22/2020
The date that a record was last updated or changed.
Authorized Official Last Name: RUSSAKOV
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: ALAN
The first name of the authorized official.
Authorized Official Title or Position: PRESIDENT
The title or position of the authorized official.
Authorized Official Telephone Number: 2905741355
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 261QC1800X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider License Number 1: G75606
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
Provider License Number State Code 1: CA
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
Healthcare Provider Primary Taxonomy Switch 1: Y
Other Provider Identifier 1: 27743
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 1: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 1: CA
Other Provider Identifier Issuer 1: 27743
Other Provider Identifier 2: CFE33570
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 2: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 2: CA
Other Provider Identifier Issuer 2: LICENCE NUMBER
Other Provider Identifier 3: 28332
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 3: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 3: CA
Other Provider Identifier Issuer 3: LICENCE NUMBER
Other Provider Identifier 4: NP13918
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 4: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 4: CA
Other Provider Identifier Issuer 4: LICENCE NUMBER
Other Provider Identifier 5: 13661
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 5: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 5: CA
Other Provider Identifier Issuer 5: LICENCE NUMBER
Other Provider Identifier 6: 15489
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 6: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 6: CA
Other Provider Identifier Issuer 6: LICENCE NUMBER
Other Provider Identifier 7: 26254
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 7: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 7: CA
Other Provider Identifier Issuer 7: LICENCE NUMBER
Other Provider Identifier 8: 16903
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 8: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 8: CA
Other Provider Identifier Issuer 8: LICENCE NUMBER
Other Provider Identifier 9: A52975
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 9: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 9: CA
Other Provider Identifier Issuer 9: LICENCE NUMBER
Other Provider Identifier 10: DC0167900
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 10: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 10: CA
Other Provider Identifier Issuer 10: LICENCE NUMBER
Other Provider Identifier 11: G66831
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 11: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 11: CA
Other Provider Identifier Issuer 11: LICENCE NUMBER
Other Provider Identifier 12: 26062
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 12: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 12: CA
Other Provider Identifier Issuer 12: LICENCE NUMBER
Other Provider Identifier 13: FL32707
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 13: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 13: CA
Other Provider Identifier Issuer 13: LICENCE NUMBER
Other Provider Identifier 14: PT23734
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 14: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 14: CA
Other Provider Identifier Issuer 14: LICENCE NUMBER
Other Provider Identifier 15: 160480
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 15: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 15: CA
Other Provider Identifier Issuer 15: LICENCE NUMBER
Other Provider Identifier 16: 18301
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 16: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 16: CA
Other Provider Identifier Issuer 16: LICENCE NUMBER
Other Provider Identifier 17: 25608
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 17: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 17: CA
Other Provider Identifier Issuer 17: LICENCE NUMBER
Other Provider Identifier 18: 28612
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 18: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 18: CA
Other Provider Identifier Issuer 18: LICENCE NUMBER
Other Provider Identifier 19: G75606
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 19: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 19: CA
Other Provider Identifier Issuer 19: LICENCE NUMBER
Other Provider Identifier 20: G9700
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 20: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 20: CA
Other Provider Identifier Issuer 20: LICENCE NUMBER
Is Organization Subpart: N
Authorized Official Name Prefix Text: DR.
Authorized Official Credential Text: M.D